Random Info Flashcards
BL Adrenal Hyperplasia
Mitotante
Aldosterenoma (Conn) Labs
Hypokalemia
A:R»_space;20
When to do colectomy UC
First sign of dysplasia - usually 10 years after diagnosis
How to Stage Gastric CA
EGD BX
CT CAP / PET
Endoscopic US for staging if no mets
Most will get neoadjuvant chemo – repeat staging after this
BX for GIST - what do you see
Spindle cells, CD 117, CKIT+
Adjuvant for GIST
Imatinib - TK inhibitor – target Exon 9 / 11 (if 9, need higher dosing)
Hx for Gastric Stff
Smoking, PPI, fam / personal CA, prior scope, prior h pylori treatment
Imaging workup for suspicious GB
CT CAP and MRCP to better eval US findings
Critical View of Safety
Cystic duct, GB inferior border and common hepatic duct cleared of tissue
Must see cystic plate / liver bed in fossa with only 2 structures entering the GB
UC screening
Screen 8 years after UC diagnosis
C-Scope annually with circumferential bx every 10 cm for 33 bx
Adenomatous polyp screen
Repeat at 3 years if 3+ or over 1cm
What if you can’t do full scope in colon ca
CT colonography or enemagram
Lynch - when to scope and remove colon
Scope at 25 and annual, EGD 35
Recommend total proctocolectomy
Tumors assoc with FAP
Thyroid, desmoid, brain, colon, epidermal cyst
When to consider transanal rectal excision
Under 3 cm, under 1/3 circumference
Under 8 cm from verge
Mobile
Can get 3mm margin
No lymphovascular or perineural invasion
T 2 Rectal CA
Can do upfront surgery with LAR or APR
T3 invasion of perirectal tissue, needs neoadjuvant chemoradition therapy
If preop LN dx - preoperative XRT
when to do neoadjuvant xrt in rectal ca
T beyond muscularis or nodes
then re-stage prior to LAR or APR
Medical therapy - anal fissure
And if that doesn’t work?
Hydrate, fiber, topical nitro / lido / nifedipine
Then botox to internal sphincter
Then lateral internal sphincterotomy
Follow up for appendiceal NET
If over 2 cm, incomplete resection, mets or goblet
Serial plasma chromogranin A, CT CAP
What to assess in acute IBD flare
What must you rule out
HD stability
weight loss
anemia
nutrition
duration of steroid / biologic tx
Rule out cdiff / cmv
Neoadjuvant Chemo for Esoph
What are the next steps?
CROSS - Carboplatin, paclitaxel, radiation
Repeat labs (nutrition), EGD w/ EUS / BX and PET CT / CAP w/ Contrast
Test for Esoph Perf, and what order do they go?
- CXR
- Esophagram with gastrograffin
- thin barium
** no gastrograffin for high aspiration risk
Post op care after intervention for bleeding gastric ulcer
ICU, serial HH, PPI, Coags
What med can slow down ECF output
Octreotide
What contrast for woods lamp?
Spy?
Woods lamp – Flourescene
Spy - ICG
Plan for colon ca in setting of Lynch syndrome and mismatch genes
If Lynch – total abdominal colectomy
What if woman with Lynch
TAC and hysterectomy/oopherectomy
What to do on c scope for acute flare of IBD
Ruel out infectious
Do bx for CMV
1st Line Medical mgmt of severe UC
What do you monitor
IV steroid - monitor bm frequency, bleeding, wbc and crp
What if no response to initial steroids in severe IBD flare
Start infliximab and reasses in 5-7 days with repeat endoscopy
What if no response to steroid / infliximab?
Surgery
Indications for surgery in UC
Toxic megacolon
Perforation
Fx medical management
Dysplasia / Cancer
Tx for high output ileostomy
Aim for under 1.2 L
Silium
Fiber
Loperamide (2 tabs / 4x daily)
Then lomotil
Then: Somatostatin, oral coating, tincture of opium
What to say when ordering CT w/ IV
If Cr normal on my labs, i would get a CT with iv contrast
Bleeding GI patient - what labs?
CBC, Coags, T/S, Lactic
C scope timing for bleeding
Admit, resuscitate and give blood for 24 hours
Trend h/h
Perform C-scope following bowel prep
When to scope after diverticulitis
8-12 weeks following episode, perform c-scope to rule out CA
What tests for female with lower abdominal pain
HCG, UA, transvaginal US – plus all usual suspects
Hemangiom
Nodular peripheral/centripetal enhancement
FNH
Central scar
HCC
Hypervascular pattern with arterial enhancement and RAPID washout on PV phase
Adenoma
Hyperascular on arterial phase
Liver met
Hypodense lesion
What extra tests for any anal scc
HPV / HIV
Atypical Causes of Fissure
HIV, syphillis, Crohn’s or Neoplasm
What extra test in post pregnancy fissure
Anal manometry - don’t want to do normal things for this if low sphincter tone - do sitz bath, fiber, hydration – no dilt ointment, botox or LIST
Do endoanal advancement flap
Anti-fast bacilli and breast granulomas? dx and tx?
Granulomatous mastitis
tx - steroids
what breast lesions grow with pregnancy
Fibroadenoma and fibrocystic disease
What normal breast ca staging tests can you not do in pregnancy
What do you do instead
Typically PET CT CAP and bone scan - but in pregnancy you do chest xray and liver US
2nd trimester breast ca
Consult high risk ob
No breast conservation - can’t do radiation
Rec: mastectomy and SLNBx with radioactive tracer (no blue dye)
If trip negative – adjuvant chemothearpy
Breast conservation contraindicated in 1st / 2nd trimester – safe answer is mastectomy
If positive SLNBx – do ax node dissection because you can’t receive radiation
Chemo can be given during pregnancy so neoadjuvant chemo can be used to push back the timing of radiation
What is 2nd trimester
Weeks 13 - 28
Who can not get breast conservation
Prior radiation
1st or 2nd trimester
Collagen vascular disease
Widespread microcalcs
Who needs staging with breast CA
Inflammatory
Locally advanced
Chest wall recurrence following mastectomy
Labs for milky discharge
endocrine - prolactin, bmp, thyroid, pregnancy
What if no enlarged parathyroid seen on US
Sestamibi scan or 4d CT scan
(sestamibi better for reoperative parathyroidectomy)
Negative imagig gets 4 gland exploration
Lab test specific for Graves
Thyroglobulin stimulating assay
Thyroid stimulating ab
What labs to track with methimazole
CBC - agranulocytosis
LFT - hepatotoxic
Free t3 / t4 hould normalize, but TSH will take time to increase to normal
When to get thryoid scintigraphy
Single nodule in hyperthyroid patient – to r/o solitary toixc nodule
(Same as radioactive iodine scan)
Can treat with radioactive iodine or a lobectomy to remove the nodule
Dont biopsy a toxic nodule on US
Scintigraphy for graves – will show diffuse enlargement and uptake
WHen can you not do radioactive iodine for graves
If there is eye symptoms they can worsen with radioactive iodine
Allows post op radioactive iodine for additional treatment
Can use predictive models to determine risk from tumor factors to determine benefit of total thyroid
Who gets total thyroid for papillary ca
> 4cm
Extrathyroid extension
Metastatic ln on US or thyroidectomy
BL nodules
History of prior hypothyroidism
Tx for papillary thryoid with positive LN
If positive FNA of node – total thyroid and ipsilateral central and lateral neck dissection (if node is lateral)
Do a CT w/ IV to assess lymphadenopathy pre-op
Can biopsy suspicious node in OR and send frozen - if positive, central neck dissection and total thyroid
Order for steps for indeterminate thyroid lesion
thryoid labs
US - indeterminate
FNA - Indeterminate
Can repeat FNA and perform molecular testing vs doing lobectomy vs repeat US in 3 months with repeat FNA
If molecular is positive – do a dx lobectomy – and if it is positive for
Treatment after lobectomy for papillary thyroid ca with 2cm and no extension or nodes
no additional treatement
check thyroid funciton 6 weeks out
US in 6 months and annually
Labs for adrenal
CBC, CMP, 1 mg low dexameth, dhea, acth, renin, aldosterone and plasma metanephrines
Labs for post op hypocortisol
Hyponatremia, hyperkalemia, tachy hypotensive
High risk for post adrenal ca mets
mitotic rate
high ki 67
recommend serial imaging every 3-6 months with ct cap
Hyperaldosterone things
htn, hypokalemia, resistant bp – check serum aldo, plasma renin and bmp
Medical treatment for hyperaldos
spironolactone
After elevating liver in right side adrenal what next
continue medially until you get to lateral side of the IVC - identify the vein by identifying the renal vein and going superior
Meds for treatment of BL adrenal cortisol hyperplasia
mifepriostone, ketoconazole and mitriapone
Labs for MEN
calcitonin, cea, calcium, pth and plasma metanephrines
Imaging for MEN 2
CTCAP and Cervical US
After surgery monitor cea and calcitonin levels
Any LN positivity in melanoma needs–
staging with CT and PET CAP
MSLT 2 - if small foci in 1 node and no extracapsular invasion can elect for close observation with mri and us
How to determine LN basin in melanoma
SPECT CT lymphosyntygraphy
Follow up melanoma
H/p 3-6 months
Groin US q4 months for 2 years, then annual
Annual PET CT
Imaging for Serous Cyst adenoma
benign older females
microcystic honeycomb with stellate scar and no duct connection
low cea and amylase in fna sample
premalignant
4-5th decade female
large macrocytic in body or tail
Peripheal calcs
high cea low amylase
IPMN
communicates with main duct
high cea high amylase
Surveillance after IPMN
if high grade dysplasia – semi annual EUS and MRI alternating
Best way to assess for pancreatic cancer
if resectable then resect
if borderline then do EUS with FNA – better than ERCP brushings
BUt you need to put stent if hyperbili and getting upfront neoadjuvant therapy
Get ca 19 9 after decompressing biliary system
Hyperdense pancreative lesion on arterial phase?
Think neuroendocrine tumor
need grade and differentiation in pNETs
Sensitive test for metastatic pNET
Dotatate Pet CT – well differentiated will light up on this
remove any functional pNET
how to rule out functional pNET
fasting gastrin / insulin / glucose levels
asymptomatic pNET get removed at 2 cm size or fast growth
what abx to include if salt water or fish ingestion
Doxy for VV
Big steps of code
- Big Steps
o Initiate chest compressions
o Establish IV access
o Ensure good airway
o Work through ABCs
o End tidal over 10, 100 – 120 compressions / minute with 2 cm of chest wall movement allowing for recoil - ACLS Algorithm
o Epi 1 mg IV given every 3-5 mins
o Pulse check every 2 minutes
o Other drugs that are included
Calcium
Magnesium
Amiodarone
Lidocaine
connect AED
intubate if can’t bag mask
is pea a shockable rhythm
no pea is a non shockable rhythm
Reversible causes of coding
Hypovolemia
Hypoxia
Hypercarbia
Hypothermia
Hypo/hyperkalemia
Tension pneumo
Tamponade
Thrombosis – pulm or cardiac
Toxins
2 shockable rhythms?
V tach and V fib
V fib or v tach – which is synchronized
V tach you shock synchronized defibrillation
V fib is unsynchronized shock
